Occurrence and prevalence of bacteria on door handles at the University of Port Harcourt Teaching Hospital and the multidrug resistance implications

Background. The coronavirus disease 2019 (COVID-19) pandemic has heightened concerns regarding transmitting hospital-acquired infections through high-contact points in healthcare facilities, such as door handles, which can serve as reservoirs for pathogenic micro-organisms. With the increased infectivity of the serious acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus, there is greater awareness of the risk of multidrug-resistant bacteria on these surfaces, necessitating strict surveillance prevention protocols. Objective. This study assesses the occurrence and prevalence of bacteria on toilet door handles at the University of Port Harcourt Teaching Hospital in Nigeria and the multidrug resistance implications. We examined the hospital infection level and overall sanitary conditions. Method. Experimental data from our study on hospital door handles in different locations were assessed. Eighty-six samples were collected from toilet door handles at the University of Port Harcourt Teaching Hospital. Ethical approval was obtained from the hospital departments and the university research ethics committee. Samples from private offices and doors without handles were excluded. Bacteria were isolated from the samples, and antibiotic sensitivity testing was performed. Result. Of the 329 bacteria isolated, 55.5 % were Gram-positive and 44.4 % Gram-negative. The most prevalent bacteria were Staphylococcus epidermidis , followed by Bacillus sp. The prevalence of multidrug-resistant bacteria was also low, with Enterococcus sp. having the highest prevalence of 28.57%, followed by Micrococcus sp. at 3.45 % and S. epidermidis at 1.96 %. Conclusion. The results show that, despite the occurrence of pathogenic micro-organisms, there has been a reduction in the prevalence of multidrug-resistant bacteria strains. This study can be used as an example for environmental microbiological surveillance in suspected outbreak investigations and assessment of sanitary conditions and the prevalence of multidrug-resistant bacteria in healthcare facilities.


INTRODUCTION
The coronavirus disease 2019 (COVID-19) pandemic has significantly influenced how hospital-acquired infections are spread because of the large number of hospitalizations, resulting in multiple people touching different surfaces in healthcare facilities. High-contact points in healthcare facilities refer to areas or surfaces frequently touched by multiple people, such as door knobs, handles and railings. These surfaces can act as reservoirs for pathogenic micro-organisms that can cause infections and diseases [1]. The presence of these micro-organisms on high-contact points can pose a risk to public health because they can be transmitted from one person to another through direct contact or by touching contaminated surfaces and then touching the eyes, nose, or mouth.
Since serious acute respiratory syndrome coronavirus 2 (SARS-CoV-2 virus) is mostly transmitted by respiratory droplets, hospitals must take particular steps to stop the spread. A possible risk to the public's health and safety is the spread of contagious illnesses from nearby fomites. Inanimate items are breeding grounds for micro-organisms. However, toilet and bathroom door handles and knobs are the most typical cause of fomite infections in most hospitals [2].
Hospitals have always been concerned about the contamination of door handles with multidrug-resistant micro-organisms. The COVID-19 pandemic worsened the problem due to the high infectivity of the SARS-CoV-2 virus [3] and the related increase in antibiotic resistance in bacteria due to the increased use or misuse of antibiotics among COVID-19 patients. According to the Center for Disease Control and Prevention (CDC), multidrug-resistant bacteria are those resistant to multiple drugs, meaning they can withstand at least one antibiotic from three or more drug categories [4]. These types of bacteria are primarily detected in hospitals and healthcare facilities. They are among the most common causes of nosocomial diseases [5].
The transmission of nosocomial diseases through high-contact points in healthcare facilities is a significant concern because these infections can have serious consequences, especially for people who are already sick or have compromised immune systems [6]. Hospitals have taken further steps to address the problem of healthcare-associated infections (HCAIs), such as routine cleaning and disinfection of door handles and other high-touch surfaces, as well as requiring healthcare workers to wear personal protective equipment (PPE). One study found that due to infection prevention programmes necessitated by the pandemic, the prevalence of HCAIs with multidrug-resistant organisms has decreased [7]. We assume that strict prevention protocols have reduced the prevalence of multidrug-resistant bacteria in healthcare facilities. Fig. 1 below represents a summary of our assumption. To see if there has been a reduction in the prevalence of multidrug-resistant bacteria during the pandemic, microbial assessment of high-contact surfaces needs to be performed. Here we focused specifically on door handles. To carry out this assessment, data

Impact Statement
This study highlights the importance of maintaining and encouraging certain key aspects of hospital coronavirus disease 2019  protocols, such as constant disinfection of surfaces, hand hygiene and contactless doors, to limit the spread of hospital-acquired diseases. These practices should be standard in healthcare facilities to prevent the transmission of nosocomial diseases, particularly those caused by multidrug-resistant bacteria. Overall, this study underscores the significance of environmental microbiological surveillance in healthcare facilities during suspected outbreaks to ensure sanitary conditions and checkmate the prevalence of multidrug-resistant bacteria. The findings can guide policymakers and healthcare professionals in implementing effective infection prevention and control measures to promote public health and safety. from this experiment carried out in 2020 were analysed. A similar study by Odigie et al. pre-2019 [8, 9] is also used to support our findings.

Study site
The study site was the University of Port Harcourt Teaching Hospital (UPTH) in Rivers State, Nigeria. Ethical clearance was solicited from the university's research ethics committee; UPTH research ethics committee approval number UPTH/ADM/90/S. II/VOL.XI/840. Ethical approval was obtained from the hospital's research ethics committee after explaining the rationale for the study, the benefits and the voluntary nature of participation in the research. Permission for the study was sought and obtained from the Head of Departments at the University of Port Harcourt Teaching Hospital. The hospital is one of the two tertiary healthcare institutions in Port Harcourt, the capital of Rivers State, Nigeria. It is a multi-specialist teaching hospital with a 657-bed space offering tertiary, secondary and primary healthcare services. The hospital has an average of 5 toilets in its outpatient clinic for every 12.75 patients and a handashing basin for every 10.63 in-patients, meeting the World Health Organization (WHO) minimum requirements that prescribe 4 or more toilets for outpatient settings and 1 or more for 20 users for inpatient settings [10].

Study design and period
The study was a descriptive cross-sectional study design. It was a period prevalence survey between December 2019 and March 2020.

Inclusion criteria
Sample populations were collected from all toilet door handles in the University of Port Harcourt Teaching Hospital.

Exclusion criteria
Doors in private offices in the University of Port Harcourt Teaching Hospital and doors without handles were excluded.

Sample collection
Samples were collected aseptically from toilet doors in in-patient wards, clinics, laboratories, administrative offices/pharmacy and public toilets. Samples in our study were collected around noon, which is the hospital's peak period of patient activity.
A total of 86 samples were collected aseptically using a sterile swab stick moistened with 0.1 % peptone water. Each sample was collected by carefully swabbing the entire surface of the internal and external door handles. Sterile 6 inch sticks were used to wipe the surfaces for ~5 s. The samples were then transported using a cold chain to circumvent the overgrowth of organisms within 1 h of sample collection to the laboratory for analysis.

Enumeration of the micro-organisms
A 10-fold serial dilution was carried out; 1 ml was taken from stock (swab stick soaked in sterile diluents) using a sterile pipette into 9 ml of sterile 0.1 % peptone water for 10 −2 -10 −6 dilution. Microbial plating was carried out on a nutrient agar plate and a MacConkey agar plate. The plates were then inverted and incubated at 35 °C for 24 h for nutrient agar and MacConkey agar. After incubation, colonies were counted, and the results were recorded as colony-forming units (c.f.u.) ml −1 according to the methods of Public Health England [11]. c.f.u. ml −1 were calculated as: number of colonies counted × dilution factor volume of culture plated

Microbiological test
Further identification of isolates was carried out using the following standard biochemical tests [12]:

Antibiotic susceptibility test
The antibiotic sensitivity pattern was determined by a standardized single-disc method [13]. A colony of the test organism was picked with a sterile wire loop and immersed in peptone water. The turbidity of the suspension was compared against a reference 0.5 McFarland tube. The suspension of the organism was streaked on the entire plate of nutrient agar, and the antibiotic disc (Gram-negative disc for Gram-negative organisms and Gram-positive disc for Gram-positive organisms) was placed on the plate using forceps. The plates were incubated at 37 °C for 24 h. The following commonly-in-use antibiotics were used without any control organism: ceftazidime (CAZ) 30 µg, cefuroxime (CRX) 30 µg, gentamicin (GEN) 10 µg, ciprofloxacin (CPR) 5 µg, ofloxacin (OFL) 5 µg, amoxycillin/clavulanate (AUG) 30 µg, nitrofurantoin (NIT) 300 µg, ceftriaxone (CTR) 30 µg, cloxacillin (CXC) 5 µg and erythromycin (ERY) 15 µg.

Statistical analysis
SPSS version 23.0 was used to determine the significant difference between the frequencies of occurrence of isolates on the toilet door handles at different UPTH locations. The data for the distribution of bacteria isolates by location are expressed as the mean±standard deviation (sd) and analysed by two-way analysis of variance (ANOVA) followed by Tukey's post-hoc test. Significance is given as P<0.05.

RESULTS
A total of 329 micro-organisms were isolated, consisting of 253 bacteria (76.9 %) and 76 fungi (23.1 %). Gram-positive bacteria constituted 55.5 % of the isolated bacteria, while 44.4 % were Gram-negative.  Table 2 shows the distribution of the bacteria isolated in the different areas. The numbers in parentheses represent the percentage isolates. The results are statistically significant (P=0.05), meaning that there is a statistical difference between the bacteria isolates and between different locations.        antibiotic (cloxacillin). Gram-positive organisms were tested on Gram-positive discs, and Gram-negative organisms on Gramnegative discs. Hence not applicable (na) represents organisms that do not apply to the discs being used. Table 4 shows that 4 (28.57 %) Enterococcus sp. were multidrug-resistant, 1 (1.96 %) S. epidermidis was resistant and 1 (3.45 %) Micrococcus sp. showed resistance. At the same time, none of the other isolates was found to be multidrug-resistant. Table 5 shows that the distribution of the multidrug-resistant bacteria according to the different locations was not statistically significant (P>0.05). Of the four multidrug-resistant bacteria, two (50.0 %) were found in the laboratory area and the other two (50.0 %) were found in the clinic area.

DISCUSSION
According to our results, the prevalence of bacteria mainly associated with multidrug resistance and HCAIs is low. Such bacteria isolated in our studies are Klebsiella sp. [14], Pseudomonas sp. [15], Acinetobacter sp. [16] and Enterococcus sp. [17], which all have a mean frequency of occurrence below 10 %. This study showed that 4 (28.57 %) of the Enterococcus sp. were multidrug-resistant, while none of the other isolates were found to be multidrug-resistant. This resistant strain is usually vancomycin-resistant Enterococcus [18]. The findings of this study are in contrast to the reports of a similar study by Odigie et al. [9], where most of the bacterial isolates were multidrug-resistant. The discrepancies between these findings and our study might be because their study was carried out pre-pandemic, where hospital healthcare practices were probably less strict.
A low prevalence of multidrug-resistant bacteria generally has good effects on public health facilities. One of the most important implications is low antimicrobial resistance. This means fewer bacteria will become multi-antibiotic-resistant, thereby reducing the spread of antibiotic resistance, something public health officials and healthcare professionals are very concerned about, according to a report by the European Centre for Disease Prevention and Control (ECDC) [19]. A 2019 study by Murray et al. places Klebsiella pneumoniae, Streptococcus pneumoniae, Acinetobacter baumannii and Pseudomonas aeruginosa among the six key bacteria responsible for death due to antimicrobial resistance [20]. Our study found these bacteria to be of low prevalence, with a Streptococcus sp. frequency of occurrence <5%. Other implications of the low prevalence of multidrug-resistant bacteria includes more treatment options being available for healthcare providers, lower healthcare costs and improved infection control [21].
The most isolated bacterium was Staphylococcus epidermidis (20.16 %), followed by Bacillus sp. (18.18 %) and Micrococcus sp. (11.46 %). This is anticipated, as it is a major component of the normal flora of the skin and nostrils, which is consistent with the findings of similar studies [22,23]. This contrasts with the results of Odigie et al. [8], who found Escherichia coli to be the most frequently (92.1 %) isolated bacterium from door handle. However, Staphylococcus aureus from their study had the next highest mean frequency of isolation (87 %). The result of this study is also consistent with Itah and Ben 2004, who reported that Staphylococcus species (54.7 %) as the most frequent bacteria isolated in the hospital environment [24].
In our study, S. epidermidis showed low resistance and no occurrence of multidrug-resistant species. Bacteria such as S. epidermidis most certainly do not cause significant HCAI. This is an indication of the low occurrence of the resistant form despite its high prevalence as compared with the pre-Covid-19 study by Odigie et al. [9], where Staphylococcus species (S. pneumonia and S. aureus) were multidrug-resistant, with S. aureus being resistant to 50 % of the antibiotics. Based on our study, ciprofloxacin was the most effective antibiotic against all bacterial isolates.
The distribution of multidrug-resistant bacteria in our study locations was also statistically insignificant (P>0.05). Of the four multidrug-resistant bacteria, two (50.0 %) were found in the laboratory area, and the other two (50.0 %) were found in the clinic area. The laboratory is where these bacteria were isolated and tested, which is probably why their occurrence was high here. However, the total bacterial count distribution is statistically significant, with the clinic and ward area having a higher bacterial count. The clinic area of the hospital has been reported to be the area with the most human traffic, including patients, patients' visitors and medical personnel [22,25,26]. It has also been reported to account for a considerable occurrence of drug-resistant bacterial growth in previous studies [27,28].
To stop the spread of illness, hospitals must continue to take precautions to lessen the contamination of door handles and other high-touch surfaces and train staff members and patients on the value of good hand hygiene. At the time of this study, we did not explore the hospital's cleaning procedure or the frequency of cleaning; therefore, this might influence the prevalence of bacteria on the surfaces over time. However, with the time point of sample collection being noon during peak patient activity, we aimed to mitigate the influence of the hospital's cleaning practices on the prevalence of the isolated bacteria.
This study's relatively low occurrence of multidrug-resistant bacteria is likely attributed to the strict COVID-19 protocols at the University of Port Harcourt Teaching Hospital according to the Nigeria Centre for Disease Control (NCDC), in line with the WHO requirements. An update on the COVID-19 infection prevention and control guidelines has been available since January 2023 [29].
Further and continuous studies need to be carried out post-pandemic to maintain public health protocols and practices that mitigate the prevalence of multidrug-resistant micro-organisms. This is particularly important as a 2022 study found data indicating increased HCAIs post-COVID-19 pandemic. This has necessitated the reversion to preventive and control measures to withstand any potential pandemic [30]. A previous 2021 study showed increased COVID-19 HCAI rates since 2021 [31]. This study on the microbial assessment of door handles can therefore be used as a surveillance test to check the sanitary conditions of hospitals during a suspected outbreak and the prevalence of multidrug-resistant micro-organisms. This surveillance method can also be applied in monitoring multidrug-resistant micro-organisms' occurrence during suspected outbreaks in residential homes for elderly people.
The use of self-cleaning antimicrobial surfaces is a new and improved way to reduce hand contamination and dissemination of nosocomial pathogens within and around health facilities. Such surfaces have proven efficient, for example in the review by Butler et al. [32], which described nanocoatings and nanosurfaces with antimicrobial efficacy being employed for medical use [32]. Surface skin antibacterial door push pads and pull pads can be placed on toilet door handles within and around the hospital to reduce the spread of bacteria around the health facility. Automated motion sensor doors will also eliminate the need for door handles; however, this might constitute an economic burden for healthcare facilities, especially in primary healthcare centres in rural communities.

Funding Information
The authors received no specific grant from any funding agency.

Conflicts of interest
The authors declare that there are no conflicts of interest.

Ethical statement
Ethical clearance was solicited from the university's research ethics committee: UPTH research ethics committee approval number UPTH/ADM/90 /S. II/VOL.XI/840.

Peer review history
Dear Editor, Thank you for inviting us to submit a revised draft of our manuscript entitled, "The impact of COVID-19 healthcare practice on the prevalence of bacteria from door handles at the University of Port Harcourt Teaching Hospital and its multi drug resistance implication" with Manuscript number; ACMI-D-23-00059 to Access Microbiology. We also appreciate the time and effort you and each reviewer have dedicated to providing insightful feedback on ways to strengthen our paper. Thus, it is with great pleasure that we resubmit our article for further consideration. We have incorporated changes that reflect the detailed suggestions you have graciously provided. We hope our edits and responses below satisfactorily address all the issues and concerns you and the reviewers have noted.
To facilitate your review of our revisions, the following is a point-by-point response to the questions and comments in your letter dated 6 th June 2023.

Editor comments:
The reviewers have highlighted minor concerns with the work presented. Please ensure that you address their comments. A key point of concern with the current submission is the impact of COVID-19 healthcare practices on the presented findings.
In the absence of comparison with pre-COVID-19 data, the current title and emphasis on COVID-19 cleaning and sanitation protocols is somewhat misleading. It is recommended that the submission title and text be amended to more accurately reflect the presented study.
Response:Thank you for your comments and the general feedback. We have revised and changed the article's title to "Occurrence and prevalence of bacteria from door handles at the University of Port Harcourt Teaching Hospital and its multi-drug resistance implication" to better reflect its content as suggested. We have also limited the focus on COVID-19 and mentioned it only where it is necessary.
I thank the reviewers for taking the time to review our work and for their feedback and suggestions.

Reviewer 1 Comments:
Language: The authors should thoroughly reread this manuscript to check for grammatical errors.
Response:The manuscript has been checked and corrected for grammatical errors.
Abstract: The abstract section was appropriately structured. However, in the method section, the authors must clearly but succinctly state the sample collection method, total sample collected, ethical clearance approval, exclusion and inclusion criteria and all other methods employed in the present study. Furthermore, in the result section of the abstract, the authors did not provide any figures or data that summarize their findings. How many isolates were bacteria or fungi? How many were grampositive or negative? What was the percentage of the organisms that showed multi-drug resistance? What is the most implicated organism? What was the most effective and less-effective antibiotic etc. All these modifications must be maintained within 250 words.
Response:Thank you for the feedback on the abstract structure. The methods and result section and the entire abstract content have been modified with the incorporation of the reviewer's comment.
Impact Statement: This part is okay.
Response:Thank you.
Introduction: In line 104-105, the authors stated, "The COVID-19 pandemic has had a big influence on how hospital-acquired infections are spread, especially through contaminated door handles and other high-touch surfaces". How? I feel this part can be better connected by saying "COVID-19 pandemic has had a big influence on how hospital acquired infections are spread, owing to high hospitalizations that accompanied COVID-19 outbreak, resulting in multiple people touching different surfaces in the healthcare facilities.
In line 118-119, the authors stated, "but the COVID-19 pandemic has made the problem worse due to the high infectivity of the SARS-Cov-2 virus". How does high infectivity of SARS-Cov-2 confer antibiotic resistance on bacteria? or is the surge in antibiotic resistance in bacteria caused by increased usage of antibiotics among COVID-19 patients? Please clarify.

Response:
Line 104-105:Modified and clarification provided per the reviewer's comment. In line 203-204, was the transportation of samples carried out in cold chain to circumvent overgrowth of organisms?
In line 226-232, the authors documented procedures for antibiotic susceptibility testing. Could you also state here the antibiotics employed in this study and their respective concentrations? Also, was any control organism used for this test? If yes, kindly state it.

Response:
Line 175:Full description of the ethical clearance process has been provided, as well as the ethics committee name and approval number.
Line 200-201:The swab stick moistened with peptone water has been added to the statement.
Line 203-204:The clarification that samples were transported in a cold storage bag has been provided.
Line 226-232:The antibiotics used for the study and their respective concentration has been stated in the revised manuscript. There was no control organism used.
Results: In line 272-273, the authors stated, "consisting of 253 bacteria (76.9%) and 76 fungi (14.3 %)". These percentage values do not add up to 100%. 76/329 that accounts for fungi should be 23.1%, and not 14.3%. For the data presented in Table 1, was the experiment conducted in triplicate or duplicate? Furthermore, scientific names of organisms were not properly written. For example, in line 282, the authors wrote "Bacillus sp". The "sp" should be written without italics plus full stop after sp (e.g., Salmonella sp.).

Response:
Line 272-273:The correct percentage has been provided. The experimentation was also carried out in duplicate and has now been stated in the manuscript. Scientific names of organisms have also been corrected throughout the document.
* Line 375 -it would be good here to offer some ideas regarding why the results of your study may have differed from that of Odige et al.
* Change references to bacteria being 'low' to prevalence or rate of occurrence being low.
Response line 375:The difference in results of our study and that of Odige et al. is now provided in the revised manuscript. Although both are similar, Odige et al. study was conducted pre-pandemic and ours during the pandemic. This is likely the reason for the difference in bacteria occurrence.
* Line 388 -'epidermidis' spelling error * Use of word 'checkmate' is rather informal and confusing, I would suggest choosing an alternative.
Response line 388:the correct spelling of epidermidis has been corrected throughout the revised manuscript.
The word 'checkmate' has been revised for clarity.
* Lines 431-434 -please clarify what is meant here, it is unclear what point is being made in reference to the youth population.
Response lines 431-434:The sentence has been deleted in the revised manuscript for clarity.
* Lines 435-441 -it would be helpful to include some references to studies describing antimicrobial surfaces that could be of use here as you have mentioned them as a potential solution. Some references may be found in the following review: https:// doi. org/ 10. 1021/ acsnano. 2c12488 or the review itself may be cited (for transparency, I am an author of this review and this is a suggestion, not a requirement).
Response lines 431-434:Based on the suggestion, the study on nanocoatings and nanosurfaces with antimicrobial potential has been provided.
In discussion, explore sampling decisions -particularly timing. How can you be sure that you did not collect samples just after the surfaces were cleaned? Are you able to offer any discussion of how the prevalence of bacteria on surfaces may change over time, between cleaning events? Are you able to add detail to the methodology with respect to cleaning, for example how surfaces are usually cleaned (what types of cleaning chemicals) and how frequently.

Comments:
The reviewers have highlighted minor concerns with the work presented. Please ensure that you address their comments. Comments: As a general point, I would suggest a reduction in the emphasis on COVID-19 throughout this piece. Fundamentally, this work does not compare pre-COVID and post-COVID rates of bacteria on surfaces. It is not possible to conclude whether COVID practices have led to a decline in bacterial colonisation of these surfaces. The connection is attempted to be made, by stating that the pandemic emphasised the need to reduce HCAI transmission through high-touch surfaces; however, I would argue that the pandemic's more widespread impact was to increase emphasis on air circulation and the role of airborne viral transmission (and use of masks to combat this). I do feel, however, that this article presents some useful bacterial and AMR surveillance data from a hospital setting which is of value. The data are generally well described and discussed. * Line 104 -"The COVID-19 pandemic has had a big influence on how hospital-acquired infections are spread" -is this true? Please clarify. * Line 108 -"…microorganisms, which are organisms that can cause infections and diseases" -what is being defined here is pathogenic microorganisms or just pathogens. * Line 180 -please reference the WHO minimum requirements. * Figure 2 -ensure that bacterial names are written out in full either in the axis title or in the legend; define 'S' in 'S. epidermidis' etc. * Table 2 -need to indicate more clearly the meaning of numbers in brackets. * Table 2 -unclear what is meant by the phrase "The results are statistically significant (p = 0.05)". Which comparisons are being referred to here? * Table 3 -need justification somewhere of NA. Why were some organisms not tested against some antibiotics? * Table 4 appears to show 6 isolates that were multidrug-resistant, but Table 5 and associated text only refers to 4 isolates. References to 4 multidrug-resistant isolates are also made in the discussion. Please clarify. * Line 375 -it would be good here to offer some ideas regarding why the results of your study may have differed from that of Odige et al. * Change references to bacteria being 'low' to prevalence or rate of occurrence being low. * Line 388 -'epidermidis' spelling error * Use of word 'checkmate' is rather informal and confusing, I would suggest choosing an alternative. * Lines 431-434 -please clarify what is meant here, it is unclear what point is being made in reference to the youth population. * Lines 435-441 -it would be helpful to include some references to studies describing antimicrobial surfaces that could be of use here as you have mentioned them as a potential solution. Some references may be found in the following review: https:// doi. org/ 10. 1021/ acsnano. 2c12488 or the review itself may be cited (for transparency, I am an author of this review and this is a suggestion, not a requirement). In discussion, explore sampling decisions -particularly timing. How can you be sure that you did not collect samples just after the surfaces were cleaned? Are you able to offer any discussion of how the prevalence of bacteria on surfaces may change over time, between cleaning events? Are you able to add detail to the methodology with respect to cleaning, for example how surfaces are usually cleaned (what types of cleaning chemicals) and how frequently. Comments: Comments Language: The authors should thoroughly reread this manuscript to check for grammatical errors. Abstract: The abstract section was appropriately structured. However, in the method section, the authors must clearly but succinctly state the sample collection method, total sample collected, ethical clearance approval, exclusion and inclusion criteria and all other methods employed in the present study. Furthermore, in the result section of the abstract, the authors did not provide any figures or data that summarize their findings. How many isolates were bacteria or fungi? How many were grampositive or negative? What was the percentage of the organisms that showed multi-drug resistance? What is the most implicated organism? What was the most effective and less-effective antibiotic etc. All these modifications must be maintained within 250 words. Impact Statement: This part is okay. Introduction: In line 104-105, the authors stated, "The COVID-19 pandemic has had a big influence on how hospital-acquired infections are spread, especially through contaminated door handles and other high-touch surfaces". How? I feel this part can be better connected by saying "COVID-19 pandemic has had a big influence on how hospital acquired infections are spread, owing to high hospitalizations that accompanied COVID-19 outbreak, resulting in multiple people touching different surfaces in the healthcare facilities. In line 118-119, the authors stated, "but the COVID-19 pandemic has made the problem worse due to the high infectivity of the SARS-Cov-2 virus". How does high infectivity of SARS-Cov-2 confer antibiotic resistance on bacteria? or is the surge in antibiotic resistance in bacteria caused by increased usage of antibiotics among COVID-19 patients? Please clarify. Materials and methods: In line 175, the authors stated that ethical clearance was obtained for the study. Please provide the name(s) of the ethics committee(s) and the approval number(s) In line 200-201, the authors stated, "A totally of 86 samples were aseptically 201 collected using a moistened sterile swab stick". What was the sterile swab stick moistened with? Normal saline? Peptone water? Could you please state this. In line 203-204, was the transportation of samples carried out in cold chain to circumvent overgrowth of organisms? In line 226-232, the authors documented procedures for antibiotic susceptibility testing. Could you also state here the antibiotics employed in this study and their respective concentrations? Also, was any control organism used for this test? If yes, kindly state it. Results: In line 272-273, the authors stated, "consisting of 253 bacteria (76.9%) and 76 fungi (14.3 %)". These percentage values do not add up to 100%. 76/329 that accounts for fungi should be 23.1%, and not 14.3%. For the data presented in Table 1, was the experiment conducted in triplicate or duplicate? Furthermore, scientific names of organisms were not properly written. For example, in line 282, the authors wrote "Bacillus sp". The "sp" should be written without italics plus full stop after sp (e.g., Salmonella sp.). Discussion: In line 375-376, the authors stated, "The findings of this study are in contrast to the reports of the similar study by (Odige et al., 2018) where most of the bacteria isolates where multidrug-resistant". What do you think might be the cause of the discrepancies between your findings and those reported in other studies of a similar nature? Kindly justify this. Also, kindly ensure that "COVID-19" is written in the same manner throughout the manuscript. References: This section also needs to be corrected. Some citations were inappropriately written.

Please rate the manuscript for methodological rigour Satisfactory
Please rate the quality of the presentation and structure of the manuscript Good To what extent are the conclusions supported by the data? Strongly support Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices? No